Neurosurgery Flashcards
When would surgery be indicated for a brain abscess?
> 2.5 cm
mass effect
neurological compromise
failed aspiration or antibiotic treatment
lesions in the cerebellum
known fungal lesions
Describe the key features in the A - E approach for head injuries
C- Spine, choose to collar or not
A- if GCS < 8 intubate , jaw thrust only , avoid nasopharyngeal tubes as there may be facial bone compromise.
B- ensure ventilation and 02 sats
C- HR BP, bloods tests, IVH and IV access
D- formal GCS and repeat every 30 mins, full neuro and cranial nerve exam if conscious , pupillary examination.
E- glucose, temperature, any other injuries : look in the ears, look behing the ears, palpate the whole face and head.
What are some red flag features of a head injury?
Impaired consciousness, local neurological deficits, seizures, visual disturbances, fixed dilated pupil , base of skull fracture nausea and vomiting.
What are key questions to ask about a patient with a head injury?
all about the patient and medical history , anticoags
all about that patients head, Hx of surgery
all about the injury, blunt, penetrating
Extradural hematomas commonly occur from which type of injury?
blunt force trauma, or fall causing bony fracture with minimal displacment
Which artery is the most common to bleed in in extradural haematoma?
middle miningeal artery
What is the timecourse of clinical presentation of someone with extradural haematoma?
head injury with brief LOC, then lucid, then deteriorates.
Other symtpoms may be nausea, vomiting, ot drowsiness.
What initial investigations should you perform to investigate for a Extra dural heamatoma?
Bloods, and CT head (should be able to see the bi-conves lens and a bony fracture)
What is the indication for surgical intervention for extra haematoma?
> 30cm 3, midline shift, GCS
inbetween which layers does a sub dural haematoma occur
tearing of the bridging veins, above the arachnoid matter and below the dura matter
When may symptoms appear post a subdural haematoma?
they can occur immediately or up to months later.
What would a CT scan for a subdural haematoma show?
a convex, cresent shaped, collection of blood in one hemisphere with or without midline shift.
What are the initial management steps for a patient with a head injury
A- E
take a set of bloods and coags, and get brain imaging.
anticoagulaiton reversed
if elderley from fall refer to geriatrics for optimisation.
What are surgical managmenent options for sub dural heamatoma?
raising a bone flat or decompressive craniectmy,
What are some complications post sub dural haematoma?
celebral oedema, raised ICP, seizures, herniation. recurrent haematoma formation is common.
What are the canadian C-Spine rules?
can be used to stratify risk of cervical spine injury following trauma and aid in decision to investigate with imaging.
alert patient with GCS 15
In a stable condition A-E
You need to scan if >65, parasthesia, or high risk mechanism.
You can avoid imaging if they are currently in a sitting position, ambulatory at any time, absence of midline tenderness, delayed onset neck pain.
then carry out a ROM assessment on the neck.
When woudl surgery be indicated for a spinal fracture?
displacement, instability or neurology
What is the investigation and treatment for hydrocephalus?
Ct head. treat with ventriculoperitoneal shunt
What is the normal range for intracranial pressure?
5-15. Intervene at 20 mmHg due to severe life threatening consequences.
cerebral perfusion pressure is calculated by what?
Mean Arterial Pressure minus Intracranial Pressure
What examination findings would you find in raised ICP? early and late
Early: papillary signs, occular muscle palsies, pappiloedema,
Late: vomiting without nausea, cushings triad (irregular breathing, bradycardia and hypertension), othalmoplegia, coma, death.
What are the two devices used for monitoring intracranial pressure?
sub-arachoid bolt (ICP data only) and the external ventricular drain which can monitor pressure and drain and sample fluid
What immediate management can you offer a patient with an intracerebral bleed?
stabilise and resusitate
need to get BP down
reverse anticoagulation
anti-seizure prophylaxis
When is surgical management recommended for an intracerebral stroke?
cerebellar bleeds, craniotomy and craniectomy
what are risk factors for cerebral aneurysm?
female, family history, smoking, hypertension, autosomal dominant polycystic kidney disease, and CT disorders like Marfans.
Which aneurysm has the highest risk fo rupture?
posterior and > 24 mm
What is the surgical treatment of cerebral aneurysms?
surgical clipping or endovascular coiling the aneurysm
How can cerebral abscesses be surgically managed?
burr hole and needle aspiration or crantotomy and excision of the abscess cavity entirely
What types of brain infections require surgical intervention?
sub-dural empyema , extra dural abscess and cerebral abscess.
What is the initial investigation for a sub -arachnoid haemohhrage?
urgent non con CT head, can also do an LP , then digital subtraction CT angiogram to identify the source of the bleeding
What is the intial management of someone with a SAH?
resusitation
send to neurosurgery centre
give nimodipine a calcium channel blocker to reduce any risk of vasospasm
What are complications of post subarachnoid aneurysm clipping?
rebleed, vasospasm, increased ICP, hyponatraemia. seizures.
What is the most common hormone secreted by a functioning pituitary adenoma?
prolactin.
growth hormone
no hormore
ACTH
gonadotropin
TSH
What are some clinical feautres of a pituitary adenoma?
can present with the mass effect or hormonal effects.
Mass effect: bitemporal hemianopia, heataches , cranial nerve patholgoy
What surgical appraoch is used for surgical resection of pituitary tumours?
trans sphenoidal
What would be some post pituatary removal complications to be aware of?
diabetes insipidus, CSF leak, meningitis, bleeding and endocfrine disturbances,
what are some causes of cauda equina syndrome?
discitis or disk protrusion anywhere from L1 to S5. trauma. neoplasm. infection. chronic spinal inflammation. iatrogenic i.e hematoma from spinal anesthesia.
What are some signs and symptoms of cauda equina syndrome?
saddle anaesthesia, fecal incontinence, urinary retention, lower limb sensation reduced and motor weakness, severe back pain. complete the examination with a full neurological evaluation of the upper limb.
cauda equina will have only lower motor neuron signs.
What is the gold standard for investigation of cauda equina syndrome?
MRI spine
What is the surgical treatment for cauda equina?
urgent surgical decompression.
What are some clinical features of spinal cord compression?
upper motor neuron findings (hypertonia, hyperreflexia, upgoing babinski,
lower limb weakness
sensation and propriocention will be impaired
If you MRI demonstrates spinal cord compression what initial medical management can you give
high dose corticosteroids and also PPI
What is the definition of brain death?
abscence of brainstem reflexes
motor responses
brainstem respiratory drive
deeply unconscious patient
irreversible brain problem (with known cause)
absence of contributing metabolic derangements
how is brainstem death different to persistive vegetative state
brainstem death is when the body required ventilation and will continue to multi organ failure without it.
What are some brainstem reflexes for testing?
papillary reflexes
corneal reflex
occulo-vestibular reflex: cold water in the ear
painful stimuli at V1 of CN 5 at the occular bridge
gag reflex
cough reflex with a branchial catheter
apnoea at the end
